Overtime Claims
The Case Review Questionnaire is designed to provide this office with the basic  and essential information needed to review your matter. Completing this form and providing it to this office does not mean this office is representing you as legal counsel. The form will be reviewed by this office and you should receive some feedback within the near future. The completion of this form, and review of this information, by no means establishes an attorney/client relationship between yourself and this office. This relationship can only be established after you and this office enter into a written attorney’s fee agreement.

Please clearly write out the information requested below. If a question does not apply to you, leave it blank or write “N/A” in the space provided.

GENERAL INFORMATION QUESTIONNAIRE

Please review this form and complete all information requested. If a question is not applicable to you, simply type "N/A" in the space after the question.

This information will be reviewed by this office in deciding whether this office is willing to represent you in a legal proceeding. The completion of this form, and review of this information, by no means establishes an attorney/client relationship between yourself and this office. This relationship can only be established after you and this office enter into a written attorney’s fee agreement.

The information contained herein is covered by the attorney/client privilege and should be completed and reviewed by the possible client of this law firm.

1. Personal and Family History
Full name
Current home address	City State Zip
Home phone
Business phone
Cellular phone
Pager
E-Mail Address
Your Social Security number
2. Place of Birth
Birthplace
Date
Have you ever used any other date or place of birth? If so, explain.
3. Marriage Status
Are you presently married?	Yes No
Name of Spouse
Children, if so, state names and ages:
4. Your Employer – Pay Information In this section, you should provide the information regarding the employer that you are making a clam against.
Employer’s Name:
Employer’s Complete Address:	City State Zip
Employer’s phone Number
Where is employer’s headquarters located (City, State):
Estimated Number of employees in your State
Estimated Number of employees in other States
Date you started working there:
Your last day working there: (if applicable):
Your job title(s) while working there:
Estimated number of employees company-wide with the same job title or function as you:
Immediate Supervisor’s Name & Title :
How were you paid: (pick one)	Paid by Hour Paid a flat salary        regardless of hours worked
Beginning pay rate (either per hour or per year)
Ending pay rate (either per hour or per year)
Average number of hours you work per week:
If you reported the hours you worked, how was this done:	Time clock  Recorded on computerized system Recorded on handwritten paper Other
If “Other,” please describe:
Did you receive any type of bonus pay or commissions at your job?  If so, please describe the amount(s) and when they were paid.
Were you ever required to be at work, but not get paid for the time that you were there?  (For example, required to show up early or stay late off the clock). If yes, please explain:
Are you a member of a labor Union?	Yes No
If so, what union:
As part of this job, were you required to attend any type of binding arbitration to resolve any employment disputes?	Yes No
5. Job Duties
Give a general description of your daily job duties (what did you actually do most days at work)?
Did you ever provide advice to management on how their business was run?	Yes No
Did you ever provide advice to management on how to manage its business?	Yes No
Did you ever represent the company in any negotiations, purchasing, promoting its services, or research regarding its business?	Yes No
What type of daily judgments or decisions did you make, if any, during a normal workday? Describe.
Did you consider your work clerical in nature?	Yes No
Did you have any supervisory authority over any employees?	Yes No
Did you conduct any performance reviews for any other employees?	Yes No
Could you fire or hire any employees?	Yes No
Did you ever deliver company property from one location to another using a vehicle? If so, please describe.
Do you have any professional degress or certificates that are required for your job? If so, please describe.
6. Educational Background
What education have you had, including any special job training (list high school, college, college courses, degrees, etc. and dates of each of these)
7. Criminal History:
Other than speeding and parking tickets, state any incident that you were charged with any criminal violation, when this occurred, where it occurred, and the outcome (i.e. plea agreement, conviction).
8. How did you learn about this office:
Please describe how you learned to contact this office for review of your matter (such as referral, advertisement, internet search, etc…).